roots C.E. No. 3, 2013

Cover / Editorial / Content / Diagnosis 2013: The things you need to know for successful endodontic treatment / Bioactive endodontic obturation: Combining the new with the tried and true / Phast Pips: The photoacoustic wave of the future? / ‘The practice of endodontics is exciting’ / AAE holds its annual meeting in Honolulu / Wykle Research expands its Calasept Endo line / Submissions / Imprint

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Table of contents

roots
issn 2161-6558

the international C.E. magazine of

3

2013

_C.E. article
Diagnosis 2013: The
things you need to know
for successful endodontic
treatment

_technique
Bioactive endodontic
obturation: Combining the
new with the tried and true

_trends
PHAST PIPS: The
photoacoustic wave
of the future?

North America Edition • Vol. 4 • Issue 3/2013

endodontics

[2] =>

[3] =>

editorial _ roots

Honoring those
who save teeth
There is perhaps nothing more satisfying than the ability to save a patient’s tooth. I know this from
decades of clinical experience. Probably most endodontists would agree with me on this — especially those
who have devoted their careers to practicing and teaching.
I’m talking about people like my longtime friend Dr. Samuel O. Dorn, pictured with me at this year’s AAE
Annual Session in Honolulu. Dorn received the Edgar D. Coolidge Award, the AAE’s highest honor. He was
one of many endodontists who received awards at the meeting.
You can read my interview with Dorn by turning to page 24.
Also in this issue of roots, you will want to check out the article on bioactive obturation using MTA
Fillapex and the Continuous Wave of Condensation technique, by Dr. Gary Glassman. There’s also a report
on photon induced photoacoustic streaming (PIPS) by Dr. Reid Pullen.
But that’s not all. Every issue of roots also contains a C.E. component. By reading the article on diagnosis
by Dr. Thomas Jovicich, then taking a short
online quiz about this article at www.
DTStudyClub.com, you will gain one ADA
CERP-certified C.E. credit. Keep in mind
that because roots is a quarterly magazine,
you can actually chisel four C.E. credits per
year out of your already busy life without
the lost revenue and time away from your
practice.
To learn more about how you can take
advantage of this C.E. opportunity, visit
www.DTStudyClub.com. You need only
register at the Dental Tribune Study Club
website to access these C.E. materials free of charge. You may take the C.E. quiz after registering on the
DT Study Club website.
I know that taking time away from your practice to pursue C.E. credits is costly in terms of lost revenue
and time, and that is another reason roots is such a valuable publication.
I hope you will enjoy this issue and that you will take advantage of the C.E. opportunity.

Fred Weinstein, DMD, MRCD(C),
FICD, FACD

Sincerely,

Fred Weinstein, DMD, MRCD(C), FICD, FACD
Editor in Chief

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I content_ roots

page 12

page 06

I C.E. article

I industry

06	Diagnosis 2013: The things you need to know
for successful endodontic treatment

28

_Thomas Jovicich, MS, DMD

I technique
12	Bioactive endodontic obturation: Combining the
new with the tried and true

page 20

Wykle Research expands its
Calasept Endo line

I about the publisher
29
30

_submissions
_imprint

_Gary Glassman, DDS, FRCD(C)

I trends
20	PHAST PIPS: The photoacoustic wave of the
future?
_Reid Pullen, DDS, FAGD

I interview
24

roots

North America Edition • Vol. 4 • Issue 3/2013

issn 2161-6558

the international C.E. magazine of

endodontics

3

2013

_C.E. article
Diagnosis 2013: The
things you need to know
for successful endodontic
treatment

‘The practice of endodontics is exciting’
_Fred Weinstein, Editor in Chief

_technique
Bioactive endodontic
obturation: Combining the
new with the tried and true

_trends
PHAST PIPS: The
photoacoustic wave
of the future?

I meetings
26

AAE holds its annual meeting in Honolulu
_Fred Michmershuizen, Managing Editor

page 24

04 I roots
3_ 2013

I on the cover

Image by Reid Pullen, DDS, FAGD.

page 26

page 28

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I C.E. article_ diagnosis

Diagnosis 2013:
The things you need
to know for successful
endodontic treatment
Author_Thomas Jovicich, MS, DMD

_c.e. credit
This article qualifies for C.E.
credit. To take the C.E. quiz, log
on to www.dtstudyclub.com.
Click on ‘C.E. articles’ and
search for this edition (Roots
C.E. Magazine — 3/2013). If
you are not registered with the
site, you will be asked to do so
before taking the quiz. You may
also access the quiz by using
the QR code below.

_The goal of endodontic treatment is for the clinician to achieve an effective cleaning and debridement of the root canal system, including the smear
layer and all of its mechanical and bacterial byproducts. Traditionally this is accomplished via mechanical instrumentation in conjunction with chemical irrigants together and actively engaged to completely
debride and sterilize the root canal system.
The root canal system is a vast and complex threedimensional structure comprising deltas and lateral
canals, along with multiple branches off of the main
root canal system (Figs. 1, 2, 9).
Before the clinician can begin to treat a patient
in need of endodontic treatment, he or she first
must come up with the proper diagnosis. Once the
diagnosis has been made, it then must be integrated
with the treatment plan. Taking that treatment plan
and presenting it to the patient creates the next
challenge: creating value for the patient. One of my
most difficult challenges as a working endodontist
is creating value for the patient in my chair who has
no pain and is here because his or her dentist “saw

Fig. 1_Maxillary molar. Note the
complex anatomy and multiple
portals of exit. (Photos/Provided by
Thomas Jovicich, MS, DMD)
Fig. 2_Mandibular molar. Note the
curvature along with the multiple
portals of exit.

06 I roots
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Fig. 1

Fig. 2

something” on the radiograph. Pain is the greatest
patient motivator we have in dentistry today.
The focus of this article is on diagnosis, and it is
my goal to provide the reader with a good grasp of
diagnosis as it relates to endodontic treatment.
Endodontics is all about vision. You have it. I have
it. The dentist down the street has it. Doing root canals
today is all about having the confidence to make the
proper diagnosis. This is achieved through repetition.
The more you do it, the easier it becomes. In addition,
you need consistency that is achieved through positive
reinforcement. Once you believe you can do it and the
results support that, you then develop competence.
This allows you to retain the skills you have worked hard
to hone. The most important trait to utilize in clinical
practice today is common sense. This is what separates
the true artisans from tooth mechanics.
The key component to endodontic treatment is
diagnosis. It is based upon using a multifocal approach that involves:
• Patient report
• Medical and dental history
• Clinical signs and symptoms
• Diagnostic testing
• Radiographic findings
• Restorability
Taking and collating all of this information will
allow the clinician to arrive at a proper and thorough
diagnosis. Let’s break these down and delve into what
needs to be done.

[7] =>

C.E. article_ diagnosis

Fig. 3a

Fig. 3b

_Patient report
This is the first opportunity to create a road map to
a diagnosis. The goal is to ascertain the nature of the
problem. Step one: Ask the patient the where the pain
is located. Once you’ve localized the area, it’s imperative to ask a few more questions. The next question
should involve determining pulpal vitality through
the use of an ice pencil.
Other times the patient will volunteer this information with a statement like: “The minute I put anything cold on this tooth, the pain is present and quite
intense.” This information suggests that the pain may
be pulpal in origin. Because the trigeminal nerve is
involved in endodontics, it is important to determine
any type of radiating pain. It is not uncommon for
maxillary pain to radiate from the mandibular area
and vice versa. A final area of feedback I want from
patients relates to biting and chewing.
The patient’s report is the foundation upon which
we begin the diagnostic procedure. Asking probing
and leading questions in “plain English” will allow the
patient to give you critical diagnostic information.

_Medical and dental history
Once you have the patient’s report, probing his
or her medical and dental history gives clarity to the
background. What are the patient’s medical allergies? What recent dental treatment has the patient
had? Was there any mention of restorations placed
that were near or at the pulp?
Many times a patient will mention having heard
the dentist tell his assistant that they were close to
the pulp during the excavation of decay. Asking detailed questions enables you to enrich the diagnostic
canvas as to why the patient is sitting in your chair.

_Clinical signs and symptoms
By this point, you have listened to the patient’s
chief complaint and you have taken radiographs or
digital images. It’s time to “test” the patient. The “bite
test” involves having the patient attempt to reproduce the pain through biting on an orangewood stick

Fig. 4a

or a cotton swab or a wet cotton roll. If there is pain
to bite, you are dealing with some degree of pulpal
inflammation with secondary involvement of the
periodontal ligament. Once you have this information, the next step is to look at your digital imaging
and analyze the relationship of the periodontal ligament (pdl) to the root. Is there a thickening? Is there
a widening?
If the patient reports pain to bite upon release, this
infers that there may be some structural root damage
(Figs. 5a, b). At that point is it essential to look at the
occlusal surface of the tooth, account for the type
and age of any restoration and inquire if any recent
dentistry has been done. In addition, it is imperative
to probe the suspected tooth.
Probing from buccal to lingual with at least four
measurements per side is the best barometer to assess periodontal health. If you find an isolated defect
in any single probing, you are most likely dealing
with a fracture of the root. Endodontic treatment
to confirm or rule out a fracture is indicated in these
clinical situations.

Fig. 4b

Fig. 3a_Maxillary central incisor with
a periapical lesion. This is a markedly
calcified canal.
Fig. 3b_Maxillary central incisor
with completed root canal using
Sybron TFA rotary nickel titanium
instruments, Sealapex sealer. Note
the multiple portals of exit in the
apical region.
Fig. 4a_The presence of caries
under the margin of a restoration.
The caries extend to the pulp and will
need endodontic treatment.
Fig. 4b_The endodontic treatment is
completed. In this case, the patient
was lost to the practice for three
years and came back when his face
was swollen because of incomplete
treatment.

_Diagnostic testing
The percussion test involves using the blunt end
of a mouth mirror or periodontal probe to assess for
periodontal inflammation. It is imperative that the
clinician gets a frame of reference. This is accomplished by testing the same tooth on the opposite
side of the arch. In addition, it is prudent to test the
suspected tooth as well as the teeth on either side.
Testing should involve both the occlusal and facial
surfaces.
Thermal tests utilizing hot or cold are the definitive modality to assess pulpal vitality. There are a myriad of ways to test with cold, including CO2 systems,
refrigerant sprays and ice cubes (pellets). I believe ice
pellets are the best way to test for cold symptoms. In
our practice, we use anesthetic carpules that are filled
up with water and frozen.
This method is cheap, efficient and plentiful.
The goal is to reproduce the patient’s symptoms.
Many patients who report pulpal hyperemia have
managed this symptom by utilizing the opposite

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I C.E. article_ diagnosis
manifest itself on imaging. Today’s cone-beam
imaging technology can shorten that process to
30 days. It is not uncommon to have a patient in
the chair with symptoms that you cannot quantify radiographically.

Fig. 5a_Cracked tooth syndrome.
Pre-treatment radiograph.
Fig. 5b_What can happen in a
cracked tooth when you obturate
with warm, vertical condensation of
gutta-percha.

Fig. 5a

Fig. 5b

Fig. 6_Well-done endodontic
treatment of tooth #6. Notice the
multiple portals of exit as they relate
to the presence of lesions.
Fig. 7_Know when to say when.
This dentist attempted to do an
endodontic procedure that should not
have been done.

Fig. 6

Fig. 7

side of their mouth. Temperature symptoms are a
major motivator for patients to seek dental care.
Testing with ice involves establishing a baseline to cold. Typically, I chose to test the same
tooth on the opposite side or the maxillary central
incisor. I ask patients to tell me when they feel
an “electrical shock or jolt” to the tooth. As soon
as they do that, I remove the ice from the tooth.
This is easily accomplished on the buccal surface
of the tooth at the margin of the gingiva. When
porcelain restorations are present, I strive to put
the ice right at the margin on or above any metal
margins.
Sometimes it is necessary to apply the ice on
the lingual aspect of the tooth. As unresponsive
as porcelain restorations can be, the clinician
needs to be aware that pulp testing gold restorations can have the opposite effect. This is
because of the metallurgical properties of gold. It
is an amazing conductor of temperature. Always
forewarn the patient when testing gold-restored
teeth.
Ask the patient if the cold on the tooth reproduced his or her pain. Also, ask if the pain lingered
after you removed the ice from the test site. If
the pain it is lingering, it is a sign of irreversible
pulpitis.
In some cases the pain can and does radiate along
the pathway of the trigeminal nerve. Sometimes,
especially in the maxilla, referred pain can be related
to sinus issues, such as sinusitis, allergic rhinitis and
rhinovirus.
If the patient does not respond to any thermal
tests, both hot and cold, it is a sign that the pulp is
necrotic, dying or infected. In this instance, studying the digital imaging may aid the diagnosis.
One caveat: It is possible to have a necrotic pulp
without being able to quantify it via digital images In many incipient pathology issues, it takes
approximately 90 to 120 days for breakdown to

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_Radiographic findings
Radiographic findings (Figs. 8a, b) are the road
map for endodontics. Thorough study and evaluation of imaging allows the clinician to determine
a multitude of facts about the tooth in question.
What does the image reveal? Can you see if there
is a widening of the pdl? If there is a widening of
the pdl, it is essential to have the patient bite down
on a bite stick.
Once he or she does that, you must ask if the pain,
if present, is worse upon bite or upon release of bite.
The latter is highly correlated with root fracture. Once
that is confirmed, the next step is to prepare the patient for a root canal.
The dentist must convincingly explain the
procedure’s value as well as caution the patient
about the possibility of losing the tooth due to
the fracture extending apical from the cementoenamel junction (CEJ). Is there a lesion (Figs. 3a, 3b)
present? This information allows me to frame my
diagnostic questions to the patient. These include:
Is the tooth sensitive to cold? I know from the lesion that the answer to that should be no. If, however, the answer is yes, it automatically triggers my
mind to look for another tooth.
Generally, speaking teeth with lesions of endodontic origin (LEOs) test non-vital to thermal
or electric pulp testing. In sequencing, I first ask
for the patient’s report, followed by radiographic
findings, which I then augment with clinical testing to tie it all together and arrive at a diagnosis.
Lastly, are caries present? The location of caries is
a determining factor as to whether a root canal is
needed (Figs. 4a, b).

_Restorability
Restorability is an issue that has been a hot
topic in dentistry for years. Its meaning has
evolved as technology has become the backbone
of modern dentistry. Prior to the incorporation of
implant dentistry, restorability had a very different
meaning. Dentists were much more motivated to
save teeth. Options and creativity were necessary
for clinical success, both in endodontics as well as
in restorative dentistry.
Technology has taken away one form of resourcefulness and replaced it with the promise of
a panacea. It has become far too easy for general
dentists to recommend removal of a tooth to a

[9] =>

C.E. article_ diagnosis

Fig. 8a_Initial digital image with a
patient whose chief complaint was
mild pain to bite and chew.

Fig. 8a

patient with the promise that an implant will save
the day.
Historically speaking, the diagnosis of a tooth
being non-restorable came after a myriad of attempts to save the tooth. Every aspect of dentistry
came into play. Periodontists did osseous surgery
and root amputations. Endodontists performed
conventional endodontics and, if necessary, surgical intervention to do everything possible to
save the tooth. Decisions involving the long-term
prognosis of the tooth were relevant. Decisions
about the type of restoration were discussed. Decisions about the osseous health of the roots and
surrounding bone structures were relevant.
The goal of every specialist is to be an extension of
the general dentist’s practice. To that end, deciding
whether a tooth was restorable or not was, at a minimum, a conversation to be had between the specialist
and the general dentist.
Leap forward to the new millennium, and dentists
no longer fight to save teeth. Dentists realize the
financial windfall that implants offer their practices.
Dentists can attend a myriad of continuing education
courses over a weekend and on Monday become nascent implantologists. This fact makes diagnosis and
saving a tooth the most important facet of restorative dentistry moving forward.
Treatment planning and restorability are integral
to success both for the patient and the dentist. A
patient in pain presents a unique opportunity for
the dentist. Many questions need to be asked and
answered. Among them: What can the dentist do
to manage the pain? What is the cause of the pain?
How long has the patient been in pain? Once the
initial triage phase is complete, other factors must
be addressed. These include: Is the tooth restorable?
If endodontic treatment is indicated, what further
treatment will be needed? Is there a need for periodontal intervention? If so, what type of treatment
is it? Osseous surgery? Does the tooth need crownlengthening surgery? How will these procedures
affect the adjacent teeth?
The above paragraph speaks volumes as to the
complexities of treatment planning in dentistry
today. Every day in offices around the world, a patient visits his or her dentist in pain. How the dentist
responds to this will go a long way in determining the

Fig. 8b

Fig. 9

patient’s dental well-being. A well-rounded practice
with high moral fiber will enable the dentist and
patient to work synergistically to develop a realistic
treatment plan.
The last essential ingredient to success is that
the dentist knows “when to say when” (Fig. 7). As
a specialist and lecturer, I believe that if a general
dentist does roughly 80 percent of the endodontic
cases that walk in the door of his practice and
refers out the remaining 20 percent, he or she
will have a very busy endodontic practice. In the
past five years, especially since the decline in the
economy and busyness of practices, more than 50
percent of my practice consists of retreatment. The
general dentist should have never attempted more
than half of those cases. I can only speculate how
much more there would be if dentists didn’t have
implants to fall back upon.

Fig. 8b_Digital photo of the tooth
after I extracted it, showing a gross
negligence. The tooth was perforated
through the furcation, and guttapercha was placed in what the
dentist thought was the root canal
system.
Fig. 9_The complexities of maxillary
molar endodontics and multiple
portals of exit. Of note, I was never
able to shape the MB2 canal.

_Implants vs. endodontic treatment
The next aspect of the diagnostic conundrum
is the increasing role implants play in treatment
planning. When I first began practicing endodontics
in 1988, implants were in their nascent stages. If a
patient had a root canal and continued to experience
pain or discomfort, both the dentist and the endodontist had a myriad of choices, from retreatment to
surgical correction. In 2013, the knee-jerk reaction
to placing implants has never been greater. More
and more general dentists go to weekend “seminars/
courses,” and on Monday morning they are placing
implants. Much of this is based on the financially
lucrative aspect of implant dentistry.
This has created polarizing arguments: save
the tooth via endodontic treatment, or extract
the tooth and place an implant. Too soon today,
dentists will opt to extract a tooth that has a questionable prognosis in favor of placing an implant.
It is my opinion that dentists should exhaust all
possible options before opting to place an implant.
Recently, I treated two of my colleagues with
cracked teeth who wanted to exhaust every option
(both were treated surgically). Ironically, they are
two dentists who are heavy into implant dentistry.
There has never been a better time to employ the
“Golden Rule” for treatment planning.

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I C.E. article_ diagnosis

‘In modern endodontics, as technology advances and we bring on file
systems that shape more efficiently and safely — and we develop a
greater understanding of the role of irrigation in endodontics — we can
offer higher success rates than at any time in history.’
What are the factors involved in the decision? Is
there enough bone to support an implant? Will you
have to augment or condition the site? If you elect
to do endodontic treatment and it fails, are you
willing to surgically try to save the tooth? If so, and
it still fails because of a fracture, by doing surgery
have you destroyed the bone? Can the patient afford to place an implant? And are they prepared for
the amount of time they may be edentulous in that
spot? All of these situations merit a thorough and
honest discussion with the patient. In addition, the
dentist needs to take into consideration the patient’s motivation to go through these procedures.
Many times I speak to patients about implants, and
they are surprised by the cost and shocked by the
time it will take before they have an implant crown
functioning in their mouths.
In modern endodontics, as technology advances
and we bring on file systems that shape more efficiently and safely — and we develop a greater understanding of the role of irrigation in endodontics
— we can offer higher success rates than at any time
in history. This paradigm starts with understanding
the patient’s symptoms and medical contraindications, correlating them with the proper diagnosis
and then having the ability to honestly look in the
mirror and decide that you can perform this treatment successfully.
These are the core decisions that need to occur on
every level of dentistry. Successful implementation
of these values and diagnostic procedures will lead
to a profitable and stress-free practice.

_Summary
Does the dentist have all of the salient dental facts?
By asking for the patient’s symptoms, you begin the
diagnostic process. From there the journey begins.
Next, does the dentist understand the patient’s chief
complaint and symptoms? Once I understand what
the patient is in my chair for, I calculate a path that
will get me the most diagnostic information. I will
need to use imaging, thermal sensitivity tests and bite
tests. Imaging gives me the direction. Once I determine the vitality and take the periodontal health into
consideration, it’s time to discuss the diagnosis and
treatment options with the patient.

10 I roots
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I always present treatment in sequences. The first
option for the patient would be to take my findings
“under advisement.” Those are patients who typically
do not present with pain and at that moment in time
do not appreciate the need for a root canal. I never
worry about those people, because nine times out of
10 they will be back in my chair sooner rather than
later. The second choice revolves around the need for
endodontic treatment.
With this option, I create value for the need for
treatment. Couple that with the patient being in
pain and wanting relief, and the decision and diagnosis is easy for this patient type. The third option
I give each and every patient involves letting him
or her know that extraction is a viable option for
his or her tooth. With that, I explain if the site is a
good candidate to receive an implant and give him
or her information on the time, cost and procedure
involved in placing an implant. It is legally very
important that your consultation and diagnosis
involve every possible option.
In sum, the goal of diagnosis is to be able to collate
the patient’s chief complaint with his or her clinical
symptoms. Once that is done, the dentist moves
through a logical progression of treatment options,
with the goal of providing excellence (Fig. 6). In this
paradigm, both the patient and the dentist benefit
from superior service and treatment._

_about the author

roots

Thomas Jovicich, MS,
DMD, is director of the West
Valley Endodontic Group,
located in the San Fernando
Valley of California. In addition to working in his private
practice, Jovicich has been
a key opinion leader for
Sybron Dental Specialties
since 2000. He lectures
around the world on current
concepts and theories in
endodontics. Jovicich also hosts a learning lab in his office
for dentists, teaching them endodontics on their patients
utilizing the latest state-of-the-art technology and materials
through the surgical microscope. He may be contacted at
thomasjovicich@mac.com.

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[12] =>

I technique_ obturation

Bioactive endodontic
obturation: Combining the
new with the tried and true
MTA Fillapex and Continuous Wave of Condensation
Author_Gary Glassman, DDS, FRCD(C)

Fig. 1a_A post-treatment image
of a maxillary first molar, which
illustrates the complex anatomy
that exists in the apical one-third of
the palatal root. (Photos/Provided
by Gary Glassman, DDS, FRCD(C),
unless otherwise noted)
Fig. 1b_A post-treatment film
of a mandibular first molar
demonstrates the importance of
shaping canals and cleaning and
filling root canal systems. (Photo/
Provided by Dr. Clifford J. Ruddle,
Santa Barbara, Calif.)

12 I roots
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_The triad of biomechanical preparation, chemotherapeutic sterilization and three-dimensional
obturation is the hallmark of endodontic success.1,2
The obturation of root canal systems represents
the culmination and successful fulfillment of a
series of highly integrated procedural steps (Figs.
1a, b). Although the excitement associated with
capturing complicated root canal anatomy is understandable, scientific evidence should support
this enthusiasm. Moving heat-softened obturation materials into all aspects of the anatomy is
dependent on eliminating pulpal tissue, the smear
layer and related debris and bacteria and their
byproducts, when present. To maximize obturation
potential, clinicians would be wise to direct treatment efforts toward shaping canals and cleaning
root canal systems.2–4
Shaping facilitates three-dimensional cleaning
by removing restrictive dentin, allowing a more
effective volume of irrigant to penetrate, circulate
and potentially clean into all aspects of the root

canal system (Fig. 2). Well-shaped canals result in a
tapered preparation that serves to control and limit
the movement of warm gutta-percha during obturation procedures. Importantly, shaping also facilitates
3-D obturation by allowing pre-fit pluggers to work
deep and unrestricted by dentinal walls and move
thermosoftened obturation materials into all aspects
of the root canal system. Improvement in obturation
potential is largely attributable to the extraordinary
technological advancements in shaping canals and
cleaning and filling root canal systems.4–6
In the article “Filling Root Canals in Three Dimensions,”7 Dr. Herb Schilder stated that while there was
merit in all obturation techniques available at that
time, “when used well … vertical condensation of
warm gutta-percha produces consistently dense,
dimensionally stable, three-dimensional root canal
fillings.” This landmark article gave birth to a paradigm shift in not only a variety of warm gutta-percha
techniques, but in a new approach to cleaning and
shaping canals, as well as irrigation protocols.8

Fig. 1a

Fig. 1b

[13] =>

technique_ obturation

Fig. 2

In addition to the classic “Schilder technique” of
obturation, there is Steve Buchanan’s “Continuous
Wave of Condensation” technique9 and variations
thereof. Vertical condensation of gutta-percha is
now one of the most-trusted obturation methods of
our time. It is taught in most of the graduate endodontic programs in North America and in a growing
number of undergrad programs as well. Its success
rate is well documented.8,10
This article will feature the Elements Obturation
Unit (Axis/SybronEndo, Coppell, Texas) that may be
used to fill root canals systems (Fig. 3a) using the
Continuous Wave of Condensation technique and
a new mineral trioxide aggregate-based endodontic
sealer that is biocompatible and bioactive, called MTA
Fillapex (MTA-F; Angelus, Londrina, Brazil) (Fig. 3b).
Mineral trioxide aggregate was developed at
Loma Linda university and in 1998 received approval
from the FDA for human use.11,12
Since then, MTA has shown excellent biological properties in several in vivo and in vitro studies.13–18 In cell culture systems, for example, MTA has
been shown to enhance proliferation of periodontal
ligament fibroblasts,15 to induce differentiation of
osteoblasts16,17 and to stimulate mineralization of
dental pulp.
In an effort to expand its applicability in endodontics, MTA-based root canal sealers have been
proposed, such as MTA Fillapex.19–22
MTA Fillapex is an endodontic sealer that combines the proven advantage of MTA with a superior
canal obturation product. Its formulation in the
paste/paste system allows a complete filling of the
entire root canal, including accessory and lateral
canals. MTA, present in the composition of MTA
Fillapex, is more stable than calcium hydroxide,
providing constant release of calcium ions for the
tissues and maintaining a pH that elicits antbacterial
effects. The tissue recovery and the lack of inflammatory response are optimized by the use of MTA and

Fig. 3a

Fig. 3b

disalicylate resin. The product is eugenol-free and
will not interfere with adhesive procedures inside
the root canal.
The two-paste system contains tricalcium silicate,
dicalcium silicate, calcium oxide and tricalcium aluminate, a salicylate resin, a natural resin and bismuth
oxide as a radiopacifing agent. The combination of
these components has been shown to have bioactive potential in its ability to stimulate nucleation
sites for the formation of apatite crystals in human
osteoblast-like cell culture.22
The two pastes of MTA Fillapex are mixed in equal
volumes and dispensed on a glass slab. Its average
working time is 35 minutes, with an average setting
time of 130 minutes.
The chemical reaction that promotes setting
in MTA Fillapex is not a polymerization reaction
between pastes but a complexation reaction. The
complexation reaction is an autocatalytic process.
A chain reaction is initiated by water molecules in
the external medium that has an intrinsic process of
self-acceleration. The complexation reaction is also
a chelation reaction where Ca(OH)2 contacts the
disalicylate resin, resulting in the entrapment of calcium ions in the compound. In addition to salicylate,
Ca(OH)2 is fundamental. The major source of Ca(OH)2
responsible for the MTA Fillapex reaction is from the
hydration of free CaO, which is in high concentration in the formula. It is therefore concluded that
the moisture present in the dentin tubules hydrates
free CaO, forming Ca(OH)2, which will react with the
salicylate and promote the setting.23

Fig. 2_Microcomputed tomography
3-D reconstruction of the mesial
root canal of mandibular molar; the
presence of an isthmus between the
root canals and multiple foramina
are evident. These areas must be
cleaned of their organic debris and
bacterial contaminants by thorough
irrigation protocols in preparation of
being three-dimensionally sealed
with thermosoftened gutta-percha.
(Photo/Provided by Dr. Ronald
Ordinola Zapata, Brazil)
Fig. 3a_The Elements Obturation
Unit replaces multiple devices while
taking up approximately one-third
the space of separate machines.
The left side of the unit incorporates
the controls and handpiece from
System-B, while the right side
incorporates the extruder system and
its controls.
Fig. 3b_MTA Fillapex is available
as a two-paste system, which must
be mixed into a homogeneous
consistency, or as a double syringe
with self-mixing tips.

_The Continuous Wave of Condensation
technique
This technique allows a single-tapered electric
heat plugger to capture a wave of condensation at
the orifice of a canal and ride it, without release, to
the apical extent of downpacking in a single, con-

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[14] =>

I technique_ obturation

Fig. 4a

Fig. 4b

Figs. 4a, b_Gutta-percha and sealer
can move into extremely small canal
ramifications by virtue of the vertical
and lateral forces created during
the simultaneous warming and
condensation of the gutta-percha.
Fig. 5_The Tip Snip can be used
to customize the apical size of the
master gutta-percha cone.

tinuous movement. Because the tip moves through a
viscosity-controlled material into a tapered-like canal form, the velocity of the thermosoftened guttapercha and sealer moving into the root canal system
actually accelerates as the downpacking progresses,
moving softened gutta-percha into extremely small
ramifications (Figs. 4a, b).
The continuously tapered root canal preparation
facilitates the fit of a suitably sized gutta-percha
cone, preferably fine-medium or medium. A clever
tool to assist with the cone fit, especially if you
choose not to use pre-sized cones or prefer nonstandardized cones, is a gutta-percha gauge such as
the Tip Snip (Axis/SybronEndo, Coppell, Texas) (Fig.
5). This allows you to customize a non-standardized
or tapered cone to a precise apical diameter. The
master cone is fit in a fluid-filled canal to more
closely simulate the lubrication effect that sealer will
provide when sliding the buttered master cone into
the prepared canal.
Further, the master cone should be able to be
inserted to the full working length and exhibit apical
tugback upon removal. It is simple to fit a master cone
into a patent, smoothly tapered and well-prepared
canal.4
The intimacy of diametrical fit between the cone
and the canal space is confirmed radiographically
(Fig. 6). The cone is then trimmed about 0.5 to 1 mm
from radiographic terminus, so that its most apical
end is just short of the working length to accommodate vertical movement of the vertically condensed
gutta-percha cone.
The System-B 0.06 or 0.08 taper, 0.5 mm plugger should fit to within 4 to 6 mm from most canal

Fig. 5

termini and is pre-fit to its binding point in the canal,
and the rubber stop is adjusted adjacent to a reference point (Fig. 7).
Difficulties in achieving adequate plugger depth
are because of deficient deep shape in the canal
preparation (inadequate enlargement 3 to 4 mm shy
of the terminus).
Stainless-steel Buchanan pluggers (Axis/SybronEndo, Coppell, Texas) are pre-fit into the canals to
their binding point. Rubber stoppers are adjusted on
these pluggers to the occlusal reference point, corresponding to 2 mm short of the apical binding point.
These pluggers are placed aside to be used later in the
backfill phase of canal obturation (Fig. 8).

_Sealer and master cone placement
MTA Fillapex (Fig. 9a) can be used for the warm
gutta-percha with vertical condensation technique
and affords several advantages.23
The presence of MTA in the formula along with
its calcium ion release allows the formation of
new tissue, including root cementum without
causing an inflammatory reaction. Perfect radiographic visualization is possible because of its
high radiopacity, and its excellent flow properties
make MTA Fillapex suitable to penetrate and fill
lateral and accessory canals. Upon setting, MTA
Fillapex expands, thereby providing an excellent
seal of the root canal, avoiding the penetration of
tissue fluids and/or bacterial recontamination. It
is available in a two-paste system, which allows
easy handling, insertion and adequate working
time to be used by both specialists and/or general

‘As the health of the attachment apparatus associated with
endodontically treated teeth becomes fully understood and
completely appreciated, the naturally retained root will be
recognized as the ultimate dental implant.’

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[15] =>

[16] =>

I technique_ obturation

Fig. 6

Fig. 6_A non-standardized (finemedium or medium) gutta-percha
cone is fit into the tapered root
canal preparation, making sure that
‘apical tugback’ has been achieved
0.5 to 1 mm short of the working
length (distance from apical
reference point will vary with canal
curvature and size).
Fig. 7_It is essential that appropriate
System-B plugger is pre-fit into each
canal to its binding point. A rubber
stop must be placed and adjusted
to the appropriate coronal reference
point for each canal.
Figs. 8a–c_Buchanan pluggers
may be pre-fit into the canals to
their binding point. Rubber stoppers
are adjusted on these pluggers
to the occlusal reference point
corresponding to 2 mm short of the
apical binding point.

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Fig. 7

Figs. 8a–c

practitioners. If retreatment is necessary it is
easily removed particularly when used with GP
points.
The amount of sealer used in this obturation technique should be minimal.
The radicular portion of the master cone is lightly
buttered with sealer and gently swirled as it is slowly
slid to length. Placing the master cone in this manner will serve to more evenly distribute sealer along
the walls of the preparation and, importantly, allow
surplus sealer to harmlessly vent coronally. To be
confident that there is sufficient sealer, the master
cone is removed and its radicular surfaces inspected
to ensure it is evenly coated with sealer. If the master
cone is devoid of sealer, then simply re-butter and
re-insert this cone to ensure there is sufficient sealer
present. When the master cone is evenly coated with
sealer and fully seated, obturation can commence.4
The canal is dried and the master cone is cemented in
the canal with sealer (Fig. 9b).
The System-B handpiece is activated by depressing the button with a gloved finger. The tip will heat
instantly, and the LED indicator on the handpiece will
illuminate. The tip will remain heated only as long as
the button is depressed. A “time-out” feature assists
the clinician by shutting off the energy to the tip after
four seconds. This will aid in avoiding overheating of
the tooth and/or tissue. The handpiece will need to
be reactivated to resume heating beyond the preset
duration.
The master cone is seared at the orifice of the
canals with the activated System-B plugger and
then gently “seated” with a larger stainless-steel
Buchanan plugger. The plugger is driven through the
center of the gutta-percha in a single motion (about
one to two seconds), to a point about 3 to 4 mm shy
of its apical binding point (Figs. 10, 11).
While maintaining pressure on the plugger,
the activation button on the System-B is released
and the plugger slows its apical movement as the
plugger tip cools (about one second) to within 2

mm from its apical binding point. After the plugger stops short of its binding point, apical pressure
on the plugger is sustained until the apical mass
of gutta-percha has set (five to 10 seconds), to
prevent any shrinkage that occurs upon cooling
(Fig. 12).

_Separation burst
After the apical mass has set, the activation button
on the System-B is depressed again, for a one-second
surge of heat. Pause for one second after this separation burst, and then remove the heated plugger and
the middle and coronal gutta-percha, leaving behind
the 4 to 6 mm apical plug of gutta-percha (Figs. 13,
14). Because these pluggers heat from their tips,
this separation burst of heat allows for quick, sure
severance of the plugger from the already condensed
and set apical mass of gutta-percha, minimizing the
possibility of pulling the master cone out. Be certain
to limit the length of this heat burst, as the goal is
separation from the apical mass of gutta-percha
without reheating.
Clinicians must be very alert during the first second of the downpack that the binding point is not
reached before completion of the downpack. If heat
is held for too long, the plugger drops to its binding
point in the canal and then cannot maintain condensation pressure on the apical mass of gutta-percha
during cooling, possibly allowing it to pull away
from the canal walls. If binding length is reached by
mistake, the heat plugger should be removed immediately, and the small end of the nickel-titanium end
of a Buchanan hand plugger (Sybron Endo, Orange,
Calif.) should be used to condense the apical mass of
gutta-percha until set.

_Backfilling
The Elements Obturation Unit (Fig. 3a) has an
extruder handpiece that accommodates dispos-

[17] =>

[18] =>

I technique_ obturation

Fig. 9

Fig. 10

Fig. 9_The master cone is cemented
in the canal with sealer.
Figs. 10, 11_With the activation
button depressed on the System-B
handpiece, the pre-fit, preheated
plugger is smoothly driven through
the mass of gutta-percha to within 4
to 6 mm of the binding point.
Fig. 12_The activation button should
be released once within 3 to 4 mm
of the apical binding point. The
plugger should slow and stop within
2 mm short of the binding point.
Apical pressure is maintained for a
full 10-second ‘sustained’ push to
prevent the cooling gutta-percha
mass from shrinking.
Figs. 13, 14_The System-B
activation button is depressed for one
second then released. The plugger
is held in position for one second
after the button is released, and the
plugger is removed with the down
pack surplus of gutta-percha, leaving
the apical seal intact. All portals of
exit may be sealed, primarily with
gutta-percha or a combination of
gutta-percha and sealer, and the
canal is ready for backfilling.

Fig. 11

Fig. 12

able preloaded cartridges of gutta-percha of
varying densities and is use to back fill the root
canal space. They are available in easy-flow,
normal-flow and heavy-body-flow viscosities.
The applicator tips are available in 20-, 23- and
25-gauge diameters. There is enough guttapercha in the disposable cartridges to fill an average four-canal molar. The author prefers to use
the heavy-body gutta-percha and a 23-gauge
applicator tip, as they are suitable for most canals
treated.
The applicator tip is placed into the root canal
space until it penetrates the coronal aspect of the
apical plug of gutta-percha for five seconds to
re-thermosoften its most coronal extent. This procedural nuance promotes cohesion between each
injected segment of warm gutta-percha.4 Segments
of 5 to 6 mm of gutta-percha are then deposited.
Injecting or dispensing too much gutta-percha
leads to shrinkage and/or voids that result in poorly
obturated canals.4 As gutta-percha is extruded from
the applicator tip, the viscosity gradient of the back
pressure produced will push the tip coronally from
the root canal space.
The technique sensitivity requires that when this
sensation occurs, the operator must sustain pressure
on the trigger mechanism as the applicator tip moves
from the canal. The Buchanan pluggers are then used
in sequence to maximize the density and homogeneity of the compressed gutta-percha mass. This
sequence of thermosoftened gutta-percha injection
and progressive compaction is continued until the
obturation of the entire root canal space is achieved
(Figs. 15-21).

_Restoration of the endodontically
treated tooth
To ensure a seamless link between the root
canal procedure and the permanent restoration
of the tooth, immediate restoration is the very

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Fig. 13

Fig. 14

best policy to protect the hard work you have
just accomplished with the previous steps. Where
temporization is necessary, ensuring a coronal
seal is crucial to long-term success. Taking a few
minutes to lay down an effective coronal seal
protects your three-dimensionally obturated root
canal from coronal leakage.8

_The future
With each improvement and modification of
the technical limitations of the technique, the thermosoftened millennium will continue to expand
the horizons of endodontic success and elevate the
standard of care and pursuit of excellence in clinical
treatment materials.1,2
As the health of the attachment apparatus associated with endodontically treated teeth becomes
fully understood and completely appreciated, the
naturally retained root will be recognized as the
“ultimate dental implant.” When properly performed,
endodontic treatment is the cornerstone of restorative and reconstructive dentistry.3_

_References
1.

3.
4.
5.
6.
7.

Glassman G, Serota S. The Thermosoftened Millennium
Revisited: Continuous Wave of Condensation, Oral Health,
December 2002, Pages 9–13.
Glassman G. Three Dimensional Obturation of the Root
Canal System: Continuous Wave of Condensation. ROOTS
The Journal of Endodontology. Vol 2, Issue 3, 2012:20–26.
Ruddle CJ: Advanced Endodontics, Santa Barbara, CA:
www.endoruddle.com, 2009.
Ruddle CJ. Filling Root Canal Systems. The Calamus 3D
obturation Technique, Dentistry Today, April 2010.
Ruddle CJ: The protaper technique, Endodontic Topics
10:187–190, 2005.
Ruddle CJ: Endodontic disinfection: tsunami irrigation,
Endodontic Practice 11:1, pp. 7–15, 2008.
Schilder, H DDS Filling Root Canals in Three Dimensions.

[19] =>

technique_ obturation

Fig. 15

Fig. 16

Dental Clinics of North America. November 1967 PG
723–744.
8. Kratchman, S. Warm Gutta Percha Revisited: Classic
Technique meets New Technology. Oral Health Dental
Journal April 2011, Pages 73–80.
9. Buchanan LS. The Continuous Wave of Condensation
Obturation Technique, Centered Condensation of Warm Gutta
Percha in 12 Seconds. Dent Today. Jan 1996, 15:60–67
10. De Chevigny C, Dao TT, Basrani BR, Marquis V, Farzaneh
M, Abitbol, S, Friedman, S. Journal of Endodontics, Vol.
34, Issue 3 pages 258–263 December 2007. Treatment
Outcome in Endodontics: The Toronto Study - Phase 4,
Initial Treatment.
11. Torabinejad M, White DJ. United States Patent 5, 415, 547
USPTO. Patent Full Text and Image Database 1995.
12. Parirokh M, Torabinejad M. Mineral trioxide aggregate:
a comprehensive literature review — part I: chemical,
physical, and antibacterial. J Endod 2010;36:16–27.
13. Holland R, Filho JA, de Souza V, Nery MJ, Bernabe PF,
Junior ED. Mineral trioxide aggregate repair of lateral root
perforations. J Endod 2001;27:281–284.
14. De Deus G, Petruccelli V, GurgelFilho E, Coutinho-Filho T.
MTA versus Portland cement as repair material for furcal
perforations: a laboratory study using a polymicrobial
leakage model. Int Endod J 2006;39:293–296.
15. Bonson S, Jeansonne BG, Laillier TE. Root-end filling
materials alter fibroblast differentiation. J Dent Res
2004;83:408–413.
16. Nakayama A, Ogiso B, Tanabe N, Takeichi O, Matsuzaka K,
Inoue T. Behavior of bone marrow osteoblast-like cells on
mineral trioxide aggregate: morphology and expression of
type I collagen and bone-related protein mRNAs. Int Endod
J 2005;38:203–210.
17. Gomes-Filho JE, de FariaMD, Barnab_e PF, et al.
Mineral trioxide aggregate but not lightcure mineral
trioxide aggregate stimulated mineralization. J Endod
2008;34:62–65.
18. Yasuda Y, Ogawa M, Arakawa T, Kodowaki T, Takashi
S. The effect of mineral trioxide aggregate on the
mineralization ability of rat dental pulp cells: an in vitro
study. J Endod 2008;34:1057–1060.

Fig. 17

Fig. 18

Fig. 19

Fig. 20

19. Bortoluzzi EA, Guerreiro-Tanomaru JM, Tanomaru-Filho M,
Duarte MAH. Radiographic effect of different radiopacifiers
on a potential retrograde filling material. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2009;108:628–632.
20. Corn_elio ALG, Salles LP, Campos da Paz M, Cirelli JA,
Guerreiro-Tanomaru JM, Tanomaru-Filho M. Cytotoxicity
of Portland cement with different radiopacifying agents: a
cell death study. J Endod 2011;37:203–210.
21. Camilleri J. The physical properties of accelerated Portland
cement for endodontic use. Int Endod J 2008;41:151–
157.
22. Salles LP, Gomes-Cornelio AL, Coutinho Guimaraes
F, Schneider Herrera B, Nair Bao S, Rossa-Junior C,
Guerreiro-Tanomaru JM, Tanomaru-Filho M, Mineral
Trioxide Aggregate–based Endodontic Sealer Stimulates
Hydroxyapatite Nucleation in Human Osteoblast-like Cell
Culture J. Endo, Volume 38, Number 7, July 2012.
23. Angelus, MTA Scientific Profile. www.angelus.ind.br

_about the author

roots

Gary Glassman, DDS,
FRCD(C), graduated from
the University of Toronto,
Faculty of Dentistry in 1984;
and graduated from the Endodontology Program at
Temple University in 1987,
where he received the
Louis I. Grossman Study
Club Award for academic
and clinical proficiency in
endodontics. The author of
numerous publications, Glassman lectures globally on endodontics, is on staff at the University of Toronto, Faculty of
Dentistry, in the graduate department of endodontics, and
is adjunct professor of dentistry and director of endodontic
programming for the University of Technology, Jamaica.
He is a fellow of the Royal College of Dentists of Canada
and the endodontic editor for Oral Health dental journal.
He maintains a private practice, Endodontic Specialists, in
Toronto, Ontario, Canada. He can be reached through his
website, www.rootcanals.ca.

Fig. 21

Figs. 15-21_Applicator tips for the
EOU System are available in sizes
#20, #23 and #25 gauges. Additional
root canal sealer may be placed in the
coronal aspect of the root canal with
a hand file prior to back filling. Fourto 6-mm increments of gutta-percha
are injected into the canal space
then immediately condensed with
the pre-fitted Buchanan pluggers
in sequence using the sequentially
larger pluggers as the coronal
aspect of the canal is approached.
As thermosoftened gutta-percha is
deposited in the canal, backpressure
is produced and the applicator is
forcibly extruded from the canal
space. It is essential that the operator
continue injecting as the applicator
tip is retrieved from the canal in
order to avoid inadvertent removal
of the newly deposited gutta-percha
mass prior to condensation.

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[20] =>

I trends_ irrigation

PHAST PIPS: The
photoacoustic wave
of the future?
Author_Reid Pullen, DDS, FAGD

_Photon induced photoacoustic streaming (PIPS)
is a low-energy (20 mJ) technique based on very short
ER:YAG laser-emitted photons introduced into an irrigation solution inside the access of the tooth. This
process, which uses the Lightwalker (Lasers4Dentistry, www.t4med.com), introduces an aggressive
and effective photoacoustic streaming or tidal wave
of irrigation solution into canals, accessory anatomy
and deep into the dentinal tubules of the root canal
system. PHAST PIPS can be described as “irrigation
on steroids.”
The goal of PHAST PIPS is to greatly enhance chemical debridement of the complete root canal system in
concert with mechanical instrumentation to reduce
the microorganism load to as low as possible.
This article will introduce four PHAST PIPS cases
and will discuss why to use PIPS, how to use PIPS and
when to use PIPS.

_Case No. 1
A 20-year-old female patient presents to the
office with instructions from her dentist stating:
“Please remove the file and finish the root canal.” The
patient’s dentist initiated root canal treatment on

Photos/Provided by Reid Pullen,
DDS, FAGD

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Fig. 1a

#18 two days prior and separated a rotary instrument
in the apical one-third of the distal canal (Fig. 1a).
Clinical testing revealed a temporary crown with
percussion and bite sensitivity. Probing, palpation
and mobility were within normal limits. Endodontic
therapy was initiated on tooth #18 with a diagnosis
of previously initiated therapy with symptomatic
apical periodontitis.
Upon access, it was noted that the coronal
shape was underprepared. The coronal flare was
completed with a ProTaper Sx (DENTSPLY) orifice
opener and Gates Glidden #2 and #3. The PIPS irrigation technique with the Lightwalker Er:YAG laser
was used for 30 seconds with the access chamber
continually flushed with 6 percent sodium hypochlorite. After applying this technique in more
than 1,500 cases, I have found that “PIPS-ing” after
the coronal flare allows easier and quicker negotiation, which then helps the clinician to obtain an
accurate working length.
After drying the three canals with the EndoVac Macrocanula, the top portion of the file was visualized. The
UT4 (eie2) ultrasonic tip was used in 10-second increments to vibrate the top of the file and create lateral space
to allow file movement and escape. After each ultrasonic

Fig. 1b

[21] =>

trends_ irrigation

Fig. 2a

Fig. 2b

Fig. 3a

Fig. 3b

use, the canals were flushed with sodium hypochlorite
and the distal canal was dried with the macrocanula to
allow visualization of the file. After the third ultrasonic
increment, the file loosened but did not dislodge. The PIPS
technique was used again for 30 seconds, alternating
with ultrasonic vibration of the file. On the third PIPS use,
the file floated out of the canal.
An accurate working length was established with
a Root ZX (J.Morita) and an open glide path created.
The canals were shaped with the WaveOne Primary
(Dentsply) reciprocating rotary file and obturated
with a resin-based sealer (Fig. 1b).

lodged. Two 30-second PIPS cycles were completed
in between and after ultrasonic use. On the third PIPS
cycle of the procedure, the file floated out of the canal.
(In some cases I was unable to remove a separated file
with ultrasonics and PIPS.)
The canal was then properly shaped and obturated
with an apical plug of zinc-oxide eugenol sealer and
gutta-percha using a warm-vertical technique. A
post space was left as requested by the general dentist. (See Figs. 2a, b.)

_Case No. 2
An asymptomatic male patient presents to the office
with a referral card with the instructions: “Please remove
the separated file, fill and leave post space.” The root
canal was initiated by his general dentist one week prior.
During the procedure, a file was separated in the palatal
canal. The dentist was able to shape and obturate the
buccal canal. The diagnosis was listed as previously initiated therapy with asymptomatic apical periodontitis.
The root canal was initiated and the access was
opened. A 30-second PIPS cycle with the Lightwalker
Er:YAG was completed with 6 percent sodium hypochlorite to clean out any residual debris. The EndoVac Macrocanula was used to remove fluid from the
canal. The top of the file was visualized through the
microscope.
The UT4 (eie2) ultrasonic tip was used in 10-second
increments to help vibrate the top of the file and to
create lateral space. The file was slightly loosened
after a few ultrasonic uses, but not completely dis-

_Case No. 3
A male patient presents to the office with a history of chewing pain and a constant ache on #14
of one-week duration. Clinical tests reveal #14 is
percussion, bite-stick and cold-test negative, and a
diagnosis is listed as pulp necrosis with symptomatic
apical periodontitis.
Root canal treatment was initiated on tooth #14, and
four necrotic canals were located. The coronal flare shape
was completed, and the PIPS (Lightwalker Er:YAG) irrigation method was used with 6 percent sodium hypochlorite for 30 seconds. A working length was obtained and
an open glide path was achieved with the Path File rotary
files (DENTSPLY). An open glide path was difficult to
achieve because of length and angulation of the canals.
The shaping procedure commenced with the
WaveOne Primary file (0.08/#25 tip, DENTSPLY).
The shaping procedure was slow and difficult, and
it took five to seven passes (a pass is defined as an
entry into the canal, up-and-down shaping, and
exiting the canal) with the WaveOne Primary file to
fully shape all four canals to working length.

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I trends_ irrigation

Fig. 4a

Fig. 4b

The PIPS technique with 6 percent sodium hypochlorite was used twice during the shaping procedure to help clear the dentinal debris. Patency was
established after every pass with a #10 K file. The
final protocol PIPS was completed to help chemically debride the root canal system, and the canals
were obturated with a zinc-oxide eugenol sealer and
gutta-percha using a warm-vertical technique.
Upon completion it was noted that an accessory canal in the palatal and a lateral canal in the midroot of the
distobuccal canals were filled with sealer. (See Figs. 3a, b.)

_Case No. 4
A male patient presents to the office with an
on-and-off toothache of approximately 10 months’
duration. Clinical tests reveal a percussion- and bitestick-sensitive maxillary first bicuspid. The tooth does
not respond to cold tests. The diagnosis is listed as
pulp necrosis with symptomatic apical periodontitis.
Radiographs show an apical and lateral radiolucency.
Root canal treatment was initiated on tooth #5, and
two necrotic canals were located. The coronal flare or
opening was completed, and a 30-second PIPS cycle
with 6 percent sodium hypochlorite was initiated. Working length and glide path were obtained, and the canals
shaped with the WaveOne Primary (DENTSPLY) reciprocating file. During the shaping procedure, a 30-second
PIPS bleach cycle was completed.
The canals were obturated with a zinc-oxide eugenol sealer and gutta-percha using a warm-vertical
technique. The post-operative radiographs showed a
lateral canal filled with gutta-percha leading to the
lateral radiolucency. (See Figs. 4a, b.)

_Conclusion
Along with mechanical debridement, the PIPS
Lightwalker Er:YAG irrigation technique shows great
potential in debridement of the root canal system,
including main canals, lateral/accessory canals, isthmuses and dentinal tubules (why to use PIPS). Various studies1,2 show that the PIPS technique greatly
reduces bacterial flora. As always, ongoing research
is needed to show how much the PIPS Lightwalker

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Er:YAG can really accomplish in debridement.
The PIPS Lightwalker Er:YAG technique works best
when the dental assistant irrigates the access continuously while suctioning any excess solution running
from the area. The trick is to keep the access chamber
full of solution so that the 4 mm unsheathed portion
of the PIPS tip stays submerged in fluid. This can be accomplished by the dental assistant moving the surgical
suction closer or farther away from the access to allow
just the right amount of solution (how to use PIPS).
I recommend using the PIPS Lightwalker Er:YAG
technique to enhance chemical debridement after the
coronal flare, once during the cleaning and shaping
phase and just prior to obturation (when to use PIPS).
I have completed more than 1,500 cases using the
PIPS as an irrigation technique. I have kept my endodontic technique nearly the same but added the PIPS
Lightwalker Er:YAG to enhance chemical debridement
(laser-assisted irrigation). Based on my clinical observation, I feel that I have a decreased post-operative sensitivity, and when I look through the microscope after the
final PIPS cycle, the canals are so exceptionally clean that
I notice the dust that the paper points give off. As far as a
better success rate, the jury is still out. It seems that since
I have incorporated the PIPS technique, I have had less
post-operative problems and better healing.
In conclusion, PIPS and the photoacoustic wave
of irrigant it produces appear to have a bright future
in endodontics._

_References
1.
2.

Peters OA, Bardsley S, Fong J, Pandher, DiVito E, JOE:p
1008–1112, Vol. 37, No. 7, July 2011
Jaramillo DE, Aprecio RM, Angelov N, DiVito E, McClamy
TV, Endodontic Practice: p 28–32 Vol. 5, No. 3, 2012.

_about the author

roots

Reid Pullen, DDS, FAGD,
graduated from USC dental
school in 1999. He was
stationed in Landstuhl, Germany, as an Army dentist
from 1999 to 2002. He completed an advanced education in general dentistry residency in the Army in 2000.
He was in general dental
private practice from 2002
to 2004 in Yorba Linda,
Calif., and then he completed the Department of Veterans
Affairs endodontic residency program in Long Beach, Calif.,
receiving his endodontic certificate in 2006. He opened his
own private endodontic practice in Brea, Calif., in 2007. He
became a diplomate of the American Board of Endodontics
in 2013. He has a wife and three children and enjoys sports,
Jiu jitsu and hanging out at the beach. He may be contacted
at reidpullen3@hotmail.com.

[23] =>

[24] =>

I interview_ Samuel O. Dorn, DDS

‘The practice of
endodontics is exciting’
Edgar D. Coolidge Award recipient Dr. Samuel O. Dorn
speaks with Editor in Chief Dr. Fred Weinstein
Author_Fred Weinstein, Editor in Chief

_Samuel O. Dorn, DDS, received the American
Association of Endodontists’ highest honor, the
Edgar D. Coolidge Award, given for leadership and
exemplary dedication to dentistry and endodontics,
during the AAE Annual Session, held earlier this year
in Honolulu.
Dorn has given much of his time to the AAE
and various other dentistry associations while also
dedicating his career to education. Since 2009, he
has served as professor and chair of the department of endodontics and director of the advanced
specialty education program in endodontics at the
University of Texas Health Science Center at Houston.
Previously, he was a professor of endodontics at the
University of Florida while also maintaining a private
practice in Fort Lauderdale, Fla.
He is also the founding director of postgraduate
endodontics at Nova Southeastern University. During his career he has received many awards honoring his dedication to the dental community, has
authored numerous articles and textbook chapters

Dr. Samuel O. Dorn with his wife,
Lindy, at the AAE meeting in
Honolulu. (Photos/Provided by AAE)

24 I roots
3_ 2013

and has lectured extensively throughout the United
States, Europe and Latin America while representing
and supporting endodontics.
In addition to serving as president of the AAE
from 2002 to 2003, Dorn served as director and
treasurer of the American Board of Endodontics
and is a past president of several local endodontic
organizations.
After the AAE meeting, Dorn answered some
questions for roots.
What are your thoughts on receiving the Coolidge
Award?
I feel very honored and humbled to receive an
award for doing what I loved to do and for giving back
to the profession that has given me and my family a
good life. Our patients are the recipients of the AAE’s
striving to save teeth. Our aim is to improve the health
of the patients we serve. I am very humble to be listed
with many of the giants of the endodontic profession
as we continue to have forward-thinking leaders who
are future recipients of this award.
What made you decide to go into endodontics?
When I graduated from dental school I wanted
to be a general dentist, because I truly enjoyed every
facet of dentistry. When I was in the Air Force at Bolling Air Force Base, three of us were selected to rotate
through the different specialties. My first rotation
was endodontics, and it turned out to be just what I
liked. I was able to help people by relieving their pain,
and I found that working in small spaces suited my
personality since I liked constructing model cars and
planes as a kid.

[25] =>

interview_ Samuel O. Dorn, DDS

Is there one thing you like best about the specialty?
I am very proud of the specialty of endodontics
and what we have done to help our patients save their
teeth. Since we first became a specialty in 1963, endodontists have been in the forefront of education for
the general dentists, as evidenced by the fact that more
than 80 percent of the endodontic treatments in the
United States are done by the GPs. The practice of endodontics is exciting in that we are constantly evolving
with new instruments and techniques, whether it’s the
use of rotary NiTi files, microscopes, cone-beam computed tomography or regeneration of the pulp. I am
also excited about new advances yet to be discovered.

The second person to influence me was Dr. Richard Moodnik, my program director. He taught me
that I could teach and become board certified even
while operating a private practice. His knowledge and
enthusiasm stayed with me for the rest of my career.

Looking back on your career, who influenced you
the most?
There are actually two people who influenced me
the most. The first was Dr. Louis Glatt, chair of endodontics at Fairleigh Dickinson University, who instilled
in me a love for, and the importance of, endodontics
as a future career path. He helped me to decide where
to apply and, once I was accepted, encouraged me to
volunteer as faculty at the school. He had me teach in
the clinic my first semester and then gave me the assignment of developing a syllabus for the senior honors course in endodontics, which I truly enjoyed. His
enthusiasm for teaching stayed with me during my
graduate program and into my private practice days.

Do you have anything you would like to add?
Endodontic treatment, when done correctly,
yields extremely high success and survivability
rates, which our profession is always striving to
increase. We have an AAE Foundation to help support endodontic research and education with an
endowment of more than $20 million contributed
mostly by members and industry, and that allows
us to use more than $1.5 million per year for these
research and education endeavors. This endowment benefits our patients, as well as the future of
our profession. I therefore would like to encourage
everyone who reads this interview to donate or to
increase their donation._

Dorn with his family.

On a personal note, is there something that people
might be surprised to know about you?
I have worked since I was 12 years old, when I had
a job delivering newspapers. In order to get through
dental school I drove a taxicab in New York City. I still
keep my taxi driver’s license over my desk to remind
myself how far I have come since those days.

roots
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[26] =>

I meetings_ 2013 AAE Annual Session

AAE holds its annual
meeting in Honolulu
Author_Fred Michmershuizen, Managing Editor

Above: AAE President Dr. James C.
Kulild addresses meeting attendees
during the President’s Breakfast.
(Photos/Fred Michmershuizen,
Managing Editor)

26 I roots
3_ 2013

_The American Association of Endodontists
held its 2013 Annual Session in April at the
Hawaii Convention Center in Honolulu, offering
plenty of educational opportunities, an exhibit
hall filled with innovative products and services,
and numerous social events.
The theme of this year’s event was “Exceeding
Expectations,” and, judging by the wide range of

technical expertise and new technology that was
on offer, it’s clear the event likely lived up to its
billing for most attendees.
The meeting offered what was called “the
largest endodontic exhibit hall in the world,”
where meeting attendees could talk to representatives from major dental and medical suppliers, explore new products and services being
offered and take advantage of show deals that
were only available in Honolulu.
Educational topics included tissue engineering, pain management, outcome assessments,
medical myths in dentistry and more. “MegaSession Wednesday,” new to the meeting this
year, allowed attendees to delve deeper into
various topics.
The always-popular Master Clinician Series
and hands-on workshops featured leading experts in topics such as “Differential Diagnosis of
Pain,” “Clinical Application of High-Resolution
CBCT in Endodontics,” “Maximizing the Value
of Your Endodontic Service” and “Functional
Crown-Lengthening Surgery.”
A number of individuals were honored with
awards.
Dr. William Powell, who is in private practice in
Knoxville, Tenn., received the President’s Award,

[27] =>

meetings_ 2013 AAE Annual Session

bestowed only nine times in the AAE’s history.
Powell was recognized for dedicating countless
hours to the advancement of the AAE since joining
in 1970.
Dr. Samuel O. Dorn received the AAE’s highest
honor, the Edgar D. Coolidge Award, given for
leadership and exemplary dedication to dentistry
and endodontics. Dorn is professor and chair of
the department of endodontics and director of the
advanced specialty education program in endodontics at the University of Texas Health Science
Center at Houston.
Dr. Peter E. Murray, an endodontics professor at Nova Southeastern University College of
Dental Medicine, received the Ralph F. Sommer
Award, in recognition of his research on regeneration of teeth and tissues.
Dr. H. Robert Steiman received the I.B. Bender
Lifetime Educator Award. Since his first appointment in 1967, Steiman has dedicated 41
years of his life to education at the University

of Detroit School of Dentistry, serving as chair
of the department of physiology, basic sciences
and endodontics, and as the director of graduate
endodontics from 1980 to 2001.
Dr. Anthony T. Borgia received the Edward M.
Osetek Educator Award. Borgia left his private
practice in February 2012 after more than 25 years
and is now the department chair and predoctoral
director in the department of endodontics at West
Virginia University School of Dentistry.
Dr. Terryl A. Propper received the Spirit of Service
Lifetime Award, for helping to build and grow the
Interfaith Dental Clinic in Nashville, Tenn., where
she is also a senior partner in a private practice.
Dr. J. Gordon Marshall received the Part-Time
Educator Award. Since obtaining his certificate
in endodontics, Marshall has been in private
practice in Vancouver, Wash., and also teaches
part-time as an associate professor in the department of endodontology at Oregon Health
and Science University._

Above: Meeting participants attend a
live Master Clinician Series educational
presentation offered by Dr. Leesa
Morrow and Dr. Donald R. Nixdorf at the
AAE meeting in Honolulu.
Across the bottom, starting from left
on previous page: Meeting attendees
gather for the opening session;
A Hawaiian band welcomes meeting
attendees with island music; Dr. Allen
Ali Nasseh offers a presentation on
the use of bioceramics in endodontic
treatment; Hal Oien, left, and Mary
McCauley of Jordco; Dr. William D.
Powell, left, receives the President’s
Award from AAE President Dr. James
C. Kulild; and Dr. C. John Munce of
CJM Engineering, left, with his wife,
Marianne.

roots
I 27
3
_ 2013

[28] =>

I industry_ Wykle Research

Wykle Research
expands its
Calasept Endo line
Fig. 1_Calasept Irrigation Needles
(Photos/Provided by Wykle Research)
Fig. 2_Calasept Irrigation Syringes

_Wykle Research has announced the release of
two new Calasept Endo products, which it distributes for Nordiska Dental of Sweden, the manufacturer of Calasept and Calasept Plus.
Calasept Irrigation Needles are high-quality,
double-side-vented, luer-lock irrigation needles
that optimize the cleansing of canals, creating a
“swirl effect.”

The needles are available in 27 g or 31 g, in packs
of 40 needles.
Features include the following:
• Bendability
• Luer-lock hub
• Sterile and disposable
• Designed for ease in cleaning roots
• High-quality stainless steel
Calasept Irrigation Syringes are 3 ml luer-lock,
single-use syringes. They are color-coded to eliminate risk when using multiple irrigation liquids. They
are available in packs of 20 syringes, 10 white and
10 green.
Features include the following:
• High-quality, three-part syringe
• Color-coded
• Luer-lock
These new products complement Wykle’s
Calasept line, which includes Calasept and Calasept
Plus calcium hydroxide paste for temporary filling
of root canals, sold in packages of four syringes
with 20 needles. Calasept EDTA is 17 percent EDTA
solution. Calasept CHX is 2 percent chlorhexidine
solution for irrigation. Both solutions are packaged
with a luer adaptor for easy filling of syringes.
Wykle Research distributes Calasept Endo
products by Nordiska Dental, a Swedish manufacturer of dental supplies. Wykle Research and
Nordiska Dental will continue to provide new
endo products.
For more information, contact Wykle Research at
(800) 859-6641 or visit the company online at www.
wykleresearch.com._

Fig. 1

Fig. 2

28 I roots
3_ 2013

[29] =>

I about the publisher_ submissions I

submissions

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We can run an extra long article in multiple parts, but this is usually discussing a subject matter where each part can stand alone
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_Questions? Comments?
Please do not hesitate to contact us for our
International C.E. Magazine Author Kit or if
you have other questions/comments about
the article submission process:
Group Editor Kristine Colker
k.colker@dental-tribune.com
Roots Managing Editor Fred Michmershuizen
f.michmershuizen@dental-tribune.com
Managing Editor Sierra Rendon
s.rendon@dental-tribune.com

		

roots
I 29
3
_ 2013

[30] =>

I about the publisher _ imprint

roots

the international C.E. magazine of endodontics
U.S. Headquarters
Tribune America
116 West 23rd Street, Ste. 500
New York, NY 10011
Tel.: (212) 244-7181
Fax: (212) 244-7185
feedback@dental-tribune.com
www.dental-tribune.com

Roots Managing Editor
Fred Michmershuizen
f.michmershuizen
@dental-tribune.com
Managing Editor
Sierra Rendon
s.rendon@dental-tribune.com

Publisher
Torsten R. Oemus
t.oemus@dental-tribune.com

Managing Editor
Robert Selleck
r.selleck@dental-tribune.com

Chief Operating Officer
Eric Seid
e.seid@dental-tribune.com

Education Director
Christiane Ferret
c.ferret@dtstudyclub.com

Group Editor
Kristine Colker
k.colker@dental-tribune.com

Marketing Director
Anna Wlodarczyk-Kataoka
a.wlodarczyk@dental-tribune.
com

Product/Account Manager
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h.estrada@dental-tribune.com
Product/Account Manager
Will Kenyon
w.kenyon@dental-tribune.com
International Product/Account
Manager
Jan Agostaro
j.agostaro@dental-tribune.com
Feedback & General Inquiries
feedback@dental-tribune.com

Editorial Board

Marcia Martins Marques, Leonardo
Silberman, Emina Ibrahimi, Igor Cernavin,
Daniel Heysselaer, Roeland de Moor, Julia
Kamenova, T. Dostalova, Christliebe Pasini,
Peter Steen Hansen, Aisha Sultan, Ahmed
A Hassan, Marita Luomanen, Patrick Maher,
Marie France Bertrand, Frederic Gaultier,
Antonis Kallis, Dimitris Strakas, Kenneth Luk,
Mukul Jain, Reza Fekrazad, Sharonit
Sahar-Helft, Lajos Gaspar, Paolo Vescovi,
Marina Vitale, Carlo Fornaini, Kenji Yoshida,
Hideaki Suda, Ki-Suk Kim, Liang Ling Seow,
Shaymant Singh Makhan, Enrique Trevino,
Ahmed Kabir, Blanca de Grande, José Correia
de Campos, Carmen Todea, Saleh Ghabban
Stephen Hsu, Antoni Espana Tost, Josep
Arnabat, Ahmed Abdullah, Boris Gaspirc,
Peter Fahlstedt, Claes Larsson, Michel Vock,
Hsin-Cheng Liu, Sajee Sattayut, Ferda Tasar,
Sevil Gurgan, Cem Sener, Christopher Mercer,
Valentin Preve, Ali Obeidi, Anna-Maria
Yannikou, Suchetan Pradhan, Ryan Seto, Joyce
Fong, Ingmar Ingenegeren, Peter Kleemann,
Iris Brader, Masoud Mojahedi, Gerd Volland,
Gabriele Schindler, Ralf Borchers, Stefan
Grümer, Joachim Schiffer, Detlef Klotz,
Herbert Deppe, Friedrich Lampert, Jörg
Meister, Rene Franzen, Andreas Braun, Sabine
Sennhenn-Kirchner, Siegfried Jänicke, Olaf
Oberhofer and Thorsten Kleinert

Tribune America is the official media partner of:

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All submissions to the editorial department are understood to be the original work of the author, meaning that he or she is the sole copyright
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Tribune America does not accept the submission of unsolicited books and manuscripts in printed or electronic form and such items will
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Tribune America strives to maintain the utmost accuracy in its clinical articles. If you find a factual error or content that requires clarification, please contact Group Editor Kristine Colker at k.colker@dental-tribune.com. Opinions expressed by authors are their own and may
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30 I roots
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